Compliance is not a four letter word. Although not mandated, the OIG (Office of the Inspector General) recommends that every small practice institute a compliance program. Legendary football coach Vince Lombardi once said, “The name of the game is to win, fairly, squarely, by the rules, but to win.” Collections in today’s environment are a game unto itself. I have been in clinics throughout the United States and it amazes me the quality of record keeping in our industry. Medical doctors, probably as a result of their time in the hospital during internship, are better record keepers. Compliance was instilled in our comrades during their training. To get better reimbursement, we need better records. Yes, it is that plain and simple; or is it?
Better Records, Better Reimbursement
Record keeping is not the most exciting portion of a modern chiropractic practice but it is, perhaps, the most important. The advantage of standardized record keeping as an important factor in healthcare almost goes without saying—but there is more: good problem-based record keeping—especially in an era where reimbursement and medical necessity are determined based on the record. Accurate record keeping allows you to give better patient care, reduce frustration, and increase income. Even more important, by learning to state patient problems and your solutions in a language and format easily understandable to third-party payers, you may be casting a vote for chiropractic as an essential component in a balanced, cost-efficient healthcare system.
There Is No Right Way to Do the Wrong Thing
More and more companies are asking for records. Your Current Procedural Terminology (CPT) must coincide with your ICD9 (International Classification of Diseases, 9th Edition). We live in a world of algorithms. If you bill it, document it; if you don’t do it, don’t document it and DON’T BILL IT. Most fraud investigations are for billing patients or services that didn’t really exist.
The same formula applies to up coding. Don’t bill something just to get a higher reimbursement. To bill a code that is not reflective of your CPT is not appropriate. Your CPT should be the code that is necessary for your diagnosis and treatment. You cannot bill a code that reflects what you may have done, if you didn’t really do it. Some clinics bill for kinetic activities instead of billing for traction, because kinetic activities have a higher reimbursement rate. Did you do traction or kinetic activities? Do not bill based on reimbursement; bill based on what you did. The OIG wants your codes to be reflective of your notes. Again, good record keeping can solve many problems.
Are Insurance 3rd Party Payers a Good Thing for Chiropractic?
Sometimes they are but, psychologically, sometimes they aren’t. There is not a lot we can do about it; or is there? The drive to regulate providers and to contain costs is now deeply entrenched. The extra paperwork takes time and staff, which is the same as time and money. The payments, which often drag their feet arriving, are often handed out at reduced rates. Most unsettling, particularly for DC’s, is that outsiders, who may or may not understand the complete scope of our practice and treatment options, often review the doctor’s work. To these people, your valuable service may not be perceived as being something that can be reimbursed. When you receive your Explanation of Benefits (EOB), respond to it. If your fee is reduced, what do you do? What can you do? If you are not happy, you can appeal it. When was the last time you appealed a claim? If your answer is, “I don’t know,” or “I don’t remember,” you are not running an organized efficient collection model.
On the plus side, Doctors of Chiropractic who fight for their due and grab the regulatory-payer-issues-for-reimbursement bull by the horns are grappling with the way of the future. Also, the payer focus on cost control has the potential to make chiropractic a rising profession. There are few other treatment modalities for many conditions that are as inexpensive or effective. Chiropractors set the standard for alternative healthcare. But why should we be the alternative? We have primary responsibilities and must demand our due. We are primary healthcare providers and should receive comparable reimbursement. First, we must document our treatment, our efficacy to show our professionalism. This makes it imperative that we submit clean claims supported by records of the highest quality, so that payers are forced to become accepting of chiropractic cost-saving advantages.
The Bridge from Here to There Is Here
So how is the doctor supposed to make the most of an insurance payer and regulatory world? KNOW THE RULES. Unfortunately, each payer seems to have it’s own conflicting rules regarding what is paid and what is not. The answer may lie in beating the payer at its own game. Once you know the “rules behind the rules” of payment regulations and protocols with modern medical record keeping, you should be able to meet the requirements of any third party administrator without pulling your hair out. This is not easy. It means reading all the articles and attending all the seminars you can. You are in a business where you want to be paid. The insurance industry only makes money by not paying claims. Insurance companies lobby groups have been stronger then ours. Most States now let the insurance companies show them the way. We will win BY SHOWING RESULTS—by documenting results. Again, this is good record keeping.
Once you know the “rules behind the rules” of payment regulations and protocols with modern medical record keeping, you should be able to meet the requirements of any third party administrator without pulling your hair out.
Compensation is a records-based business. Someone reads a form, compares what you have submitted on it to a table that lists usual and customary practices for similar ailments, and then approves or denies the claim. Unfortunately, most of the reference tables were written to deal with allopathic definitions of disease and allopathic treatments. As a DC, what you write in your records and submission documents had better match what the person scoring the form hopes to see, or you will receive only a portion of your due. Little by little, we can expect the payers to modify their tables to accommodate more from chiropractic services, but this process will take time to educate and raise awareness on the scope of benefits of our services. DC’s who are anxious for their fair share have had little leverage until now. One of our problems is we bill the same service for each visit. Then we do this as many times as we can get paid. All treatment must be based on Medical Necessity. Change your treatment as necessary; let the patients’ results mandate care, not their type of insurance
The trick is to use the language of the person reading your submission. Often your first submission will be a mathematical algorithm. CPT must equal ICD9. The amount of monies due for or treatment due for any diagnosis is budgeted. How many visits will you get for a simple sprain? Complex? Should the treatment protocols be the same? Keep that system in mind as you complete and submit your documentation, and keep it simple.
Second, while it seems that payers differ from one another in their guidelines, they do have national agencies and associations that influence their policies. The Freedom of Information Act mandates that the payer provide you with their fee schedule. Ask for it. Many organizations provide authoritative standards, which the payers use for setting their internal polices and protocols; ask for their references. To win at any game, you must understand the competition. You must recognize that they are playing to “win;” winning to them is cost containments. We have to stand up and prove the efficacy of chiropractic.
Each company, each payer seems to follow different guidelines; different rules. Where do you go; who is right? There seem to be various interpretations of standards and guidelines, but the rules (based in case law) are clear. However, strict medical standards are few and far between. They can be created only when there is consensus among experts and following scientific verification, both of which are hard to come by. Any doctor who violates a standard had best be prepared to answer for it. When a claim is denied, you have the right to an appeal. Inform the patient of your appeal. Contact your insurance commissioner. Ask for a meeting with the insurance company’s supervisor. Let them know that you are a good person, an honest person. Let your records and your word be impeccable.
Dr. Eric S. Kaplan, is CEO of Multidisciplinary Business Applications, Inc. (MBA), a comprehensive coaching firm with a successful, documented history of creating profitable multidisciplinary practices nationwide. Dr. Kaplan is the best selling author of Dying to be Young, and Lifestyle of the Fit and Famous and Co -developer and President of Discforce, the next Generation on Spinal decompression. For more information, call 1-561-626-3004